SAN LUIS OBISPO COUNTY HEALTH AGENCY Public Health Department Emergency Medical Services Division 2156 Sierra Way, San Luis Obispo, CA 93401 805-788-2511 FAX 805-788-2517 www.sloemsa.org Operations MEETING DATE Operations April 4, 2013 STAFF CONTACT SUBJECT Stephen Lieberman, EMS Director 805.788.2512 slieberman@co.slo.ca.us Tiered Response Skilled Nursing Facilities SUMMARY The San Luis Obispo City Fire Department completed a trial project in 2012, allowing Skilled Nursing Facility (SNF) medical staff to request a tiered response for patients requiring unscheduled transportation to a hospital. At the request of several Fire Chief s, a draft policy is attached for review and consideration. Highlights of the draft policy include: REVIEWED BY RECOMMENDED ACTION(S) Code 2 Ambulance-only (Fire optional) response Requires facility to have 24x7 licensed medical staff on-site Requires receiving PSAP to be an approved EMD provider Thomas Ronay, M.D., EMSA Medical Director Kathy Collins, R.N., EMSA Staff Steve Lieberman, EMS Division Director Review and provide direction/clarification to staff. ATTACHMENT(S) Draft Policy Draft Policy Attachment A Patient Assessment Flow Chart Draft Policy Attachment B Requesting Facility Narrative for Request EMD Cardset Cards impacted by adoption of draft policy K:\PublicData\COMMITTEES\Operations Subcommittee\2013\04-04-13\SNF Transfer\SNF Ambulance Request Staff Summary_Operations 03262013.docx
4/04/2013 DRAFT SAN LUIS OBISPO COUNTY EMERGENCY MEDICAL SERVICES AGENCY PREHOSPITAL POLICY Policy Reference No: Effective Date: Review Date: SUBJECT: TIERED RESPONSE PROGRAM FOR SKILLED NURSING FACILITY PATIENTS I. PURPOSE To establish a process through which skilled nursing facility medical staff may participate in a tiered response level for patients requiring unscheduled transportation to a hospital. II. AUTHORITY A. California Health and Safety Code, Division 2.5, Sections 1797.204, 1797.206, 1797.220, 1797.252, 1798 (a)(b). III. DEFINITIONS A. Code 2 Response Term used to describe an immediate response of a public safety resource without emergency lights and siren as permitted by Section 21055 of the California Vehicle Code. Also referred to as Quiet Arrival. B. Code 3 Response Term used to define an immediate response of a public safety resource with emergency lights and siren as permitted by Section 21055 of the California Vehicle Code. C. Emergency Medical Dispatch (EMD) An EMS Agency approved set of protocols to be utilized by Public Safety Answering Points for pre-arrival patient care instructions. D. EMS Agency The agency having primary responsibility for administration of emergency medical services in San Luis Obispo County (1797.94). E. Public Safety Answering Point (PSAP) A public agency dispatch center that receives emergency calls from the public or requests from another PSAP. F. Skilled Nursing Facility A facility that provides healthcare to individuals unable to manage independently in the community, and has licensed medical staff on-site 24 hours per day. P A G E 1 O F 4
G. On-Site Medical Staff Licensed medical professionals (Physician, Registered Nurse), staffing a skill nursing facility on a 24 hour daily basis. III. POLICY/PROCEDURE A. Skilled Nursing Facilities shall submit in writing to the EMS Agency a request to be approved to participate in the tiered response program. B. The EMS Agency will review each request and shall approve such request if all requirements are satisfied: 1. Requesting facility has licensed medical staff on duty 24 hours per day. 2. The jurisdictional Fire Department and PSAP submit a written letter of support for the request to the EMS Agency. 3. The jurisdictional PSAP is an EMS Agency approved EMD provider, and is compliant with EMS Agency policy and training. 4. Requesting facility shall provide written documentation detailing process for transfer, including the inclusion of appropriate patient transfer documents, and notification of/coordination with receiving hospital. 5. Final approval may include review by appropriate EMS Agency advisory committee(s). C. Upon EMS Agency approval: 1. Approved facility shall utilize attached Patient Assessment Flow Chart to determine whether a Code 2 or Code 3 response is appropriate (Attachment A). 2. Approved facility shall adopt suggested narrative information to be utilized when facility contacts the PSAP to request unscheduled patient transport (Attachment B). 3. Receiving PSAP shall append EMD cardset for the addition of Code 2 Ambulance Only Transfer Request protocol (Attachment C). 4. Skilled Nursing Facility shall participate in Quality Improvement program, and provide documentation to the EMS Agency upon request. P A G E 2 O F 4
P A G E 3 O F 4
SAN LUIS OBISPO COUNTY EMS AGENCY POLICY #XXX TIERED RESPONSE PROGRAM FOR SKILLED NURSING FACILITIES REQUESTING FACILITY NARRATIVE ATTACHMENT B 1) Identify the need for a code 2 ambulance-only transfer (Attachment A). 2) Dial 911 to initiate the request 3) State the following: This is (Name) from (approved facility name) on behalf of (R.N. or M.D. name - if not the same as caller), requesting a Code 2 Ambulance-only transfer to (Hospital). 4) Monitor patient for changes which may require an upgrade to a Code 3 response, and dial 911 with such request. 5) Confirm proper transfer documents including code status / POLST are properly prepared and ready to deliver to the transporting crew. P A G E 4 O F 4
PATIENT ASSESSMENT FLOW CHART SAN LUIS OBISPO COUNTY EMS AGENCY POLICY # TIERED RESPONSE PROGRAM FOR SKILLED NURSING FACILITIES ATTACHMENT A Patient Assessment by R.N. or M.D. Existence of any of the following: Acute or suspected stroke or stroke-like symptoms Acute uncontrolled hemorrhage Suspected acute heart problem or AMI Acute onset or difficulty breathy/respiratory distress Sudden change in LOC Acute severe hypoglycemia unresponsive to treatment Acute intractable pain Acute suspected fracture R.N. or M.D. judgment determines need for immediate transport NO YES 911 Request for Code 2 ambulance-only response 911 Request for Code 3 response Read request narrative (Attachment B) Request PSAP share any special equipment/personnel requirements with responding ambulance Provide on-scene ambulance personnel with relevant information/forms (i.e. POLST)
All Callers Interrogation 1. Where is the patient? (address or location) If the caller states patient is at (Approved Facility Name), go to Code 2 ambulance only transfer card located after All Callers Interrogation Card. 2. What is the problem / emergency? 3. Are you with the patient / line of sight? NO: Can you get to the patient? NO: Responding units Code 3. YES: Continue with EMD. Note: A physician or medical staff may request at their discretion type of response and may decline pre-arrival instruction (PAI). 4. What is the telephone number from which you are calling? 5. What is your name? (optional) 6. Is the patient conscious? (able to talk) YES: Determine age, sex, chief complaint and turn to appropriate card. NO: Dispatch Code 3 Response. Continue. 7. Is the patient breathing? Uncertain: Go and see if the chest rises, then come back to the phone. YES: Go directly to UNCONSCIOUS/UNRESPONSIVE/SYNCOPE guide card NO: Continue
2 8. If patient is not breathing or breathing is described as agonal respirations, Ask: Do you want to do CPR? I ll help you YES: Go to CPR Instructions for appropriate age group. NO: I have dispatched help. I ll stay on the line with you. If in the home or care facility ask the RP Does the patient have a written document or medallion that states No CPR? If yes inform the responding unit and stay on the line (Do not put the caller on hold unless necessary.) 9. Are there any animals or substances to be aware of? (Unusual gases, smells, etc.?)
Code 2 Ambulance-Only Request Approved Skilled Nursing Facility 3 If the caller is from (Approved Facility Name), and requests a Code 2 ambulance-only response they will state: This is (Name) from (Approved Facility Name)on behalf of (R.N. or M.D. Name if not the same as caller), requesting a Code 2 Ambulance-only transfer to (Hospital). Dispatch Ambulance Code 2 to (Approved Facility Name) Transfer without additional resources.